ABSTRACT
OBJECTIVES: The impact of age on hospital survival for patients treated with extracorporeal cardiopulmonary resuscitation (ECPR) for cardiac arrest (CA) is unknown. We sought to characterize the association between older age and hospital survival after ECPR, using a large international database. DESIGN: Retrospective analysis of the Extracorporeal Life Support Organization registry. PATIENTS: Patients 18 years old or older who underwent ECPR for CA between December 1, 2016, and October 31, 2020. MEASUREMENTS AND MAIN RESULTS: The primary outcome was adjusted odds ratio (aOR) of death after ECPR, analyzed by age group (18-49, 50-64, 65-74, and > 75 yr). A total of 5,120 patients met inclusion criteria. The median age was 57 years (interquartile range, 46-66 yr). There was a significantly lower aOR of survival for those 65-74 (0.68l 95% CI, 0.57-0.81) or those greater than 75 (0.54; 95% CI, 0.41-0.69), compared with 18-49. Patients 50-64 had a significantly higher aOR of survival compared with those 65-74 and greater than 75; however, there was no difference in survival between the two youngest groups (aOR, 0.91; 95% CI, 0.79-1.05). A sensitivity analysis using alternative age categories (18-64, 65-69, 70-74, and ≥ 75) demonstrated decreased odds of survival for age greater than or equal to 65 compared with patients younger than 65 (for age 65-69: odds ratio [OR], 0.71; 95% CI, 0.59-0.86; for age 70-74: OR, 0.84; 95% CI, 0.67-1.04; and for age ≥ 75: OR, 0.64; 95% CI, 0.50-0.81). CONCLUSIONS: This investigation represents the largest analysis of the relationship of older age on ECPR outcomes. We found that the odds of hospital survival for patients with CA treated with ECPR diminishes with increasing age, with significantly decreased odds of survival after age 65, despite controlling for illness severity and comorbidities. However, findings from this observational data have significant limitations and further studies are needed to evaluate these findings prospectively.
Subject(s)
Cardiopulmonary Resuscitation , Extracorporeal Membrane Oxygenation , Heart Arrest , Out-of-Hospital Cardiac Arrest , Humans , Adolescent , Adult , Middle Aged , Aged , Retrospective Studies , Heart Arrest/therapy , Registries , Out-of-Hospital Cardiac Arrest/therapy , Treatment OutcomeABSTRACT
BACKGROUND: Hemorrhagic shock requires timely administration of blood products and resuscitative adjuncts through multiple access sites. Intraosseous (IO) devices offer an alternative to intravenous (IV) access as recommended by the massive hemorrhage, A-airway, R-respiratory, C-circulation, and H-hypothermia (MARCH) algorithm of Tactical Combat Casualty Care (TCCC). However, venous injuries proximal to the site of IO access may complicate resuscitative attempts. Sternal IO access represents an alternative pioneered by military personnel. However, its effectiveness in patients with shock is supported by limited evidence. We conducted a pilot study of two sternal-IO devices to investigate the efficacy of sternal-IO access in civilian trauma care. METHODS: A retrospective review (October 2020 to June 2021) involving injured patients receiving either a TALON® or a FAST1® sternal-IO device was performed at a large urban quaternary academic medical center. Baseline demographics, injury characteristics, vascular access sites, blood products and medications administered, and outcomes were analyzed. The primary outcome was a successful sternal-IO attempt. RESULTS: Nine males with gunshot wounds transported to the hospital by police were included in this study. Eight patients were pulseless on arrival, and one became pulseless shortly thereafter. Seven (78%) sternal-IO placements were successful, including six TALON devices and one of the three FAST1 devices, as FAST1 placement required attention to Operator positioning following resuscitative thoracotomy. Three patients achieved return of spontaneous circulation, two proceeded to the operating room, but none survived to discharge. CONCLUSIONS: Sternal-IO access was successful in nearly 80% of attempts. The indications for sternal-IO placement among civilians require further evaluation compared with IV and extremity IO access.
Subject(s)
Emergency Medical Services , Shock, Hemorrhagic , Wounds, Gunshot , Male , Humans , Retrospective Studies , Pilot Projects , Wounds, Gunshot/therapy , Shock, Hemorrhagic/etiology , Shock, Hemorrhagic/therapy , Infusions, IntraosseousABSTRACT
Three-quarters of patients over the age of 65 visit the emergency department (ED) in the last six months of their lives. Approximately 20% of hospice residents have ED visits. These patients must decide whether to receive emergency care that prioritizes life support, which may not achieve their desired outcomes and might even be futile. The patients in these end-of-life stages could benefit from early palliative care or hospice consultation before they present to the ED. Furthermore, early integration of palliative care at the time of ED visits is important in establishing the goals of the entire treatment.
Subject(s)
Emergency Service, Hospital , Palliative Care , Humans , Referral and Consultation , DeathSubject(s)
Emergency Medical Services , Physicians , Humans , Communication , Emergency Treatment , Patient-Centered CareABSTRACT
INTRODUCTION: Acute kidney injury requiring renal replacement therapy (AKI-RRT) is common in the intensive care unit (ICU) and is associated with significant morbidity and mortality. Continuous RRT (CRRT) non-selectively removes large amounts of amino acids from plasma, lowering serum amino acid concentrations and potentially depleting total-body amino acid stores. Therefore, the morbidity and mortality associated with AKI-RRT may be partly mediated through accelerated skeletal muscle atrophy and resulting muscle weakness. However, the impact of AKI-RRT on skeletal muscle mass and function during and following critical illness remains unknown. We hypothesise that patients with AKI-RRT have higher degrees of acute muscle loss than patients without AKI-RRT and that AKI-RRT survivors are less likely to recover muscle mass and function when compared with other ICU survivors. METHODS AND ANALYSIS: This protocol describes a prospective, multicentre, observational trial assessing skeletal muscle size, quality and function in ICU patients with AKI-RRT. We will perform musculoskeletal ultrasound to longitudinally evaluate rectus femoris size and quality at baseline (within 48 hours of CRRT initiation), day 3, day 7 or at ICU discharge, at hospital discharge, and 1-3 months postdischarge. Additional skeletal muscle and physical function tests will be performed at hospital discharge and postdischarge follow-up. We will analyse the effect of AKI-RRT by comparing the findings in enrolled subjects to historical controls of critically ill patients without AKI-RRT using multivariable modelling. ETHICS AND DISSEMINATION: We anticipate our study will reveal that AKI-RRT is associated with greater degrees of muscle loss and dysfunction along with impaired postdischarge recovery of physical function. These findings could impact the in-hospital and postdischarge treatment plan for these patients to include focused attention on muscle strength and function. We intend to disseminate findings to participants, healthcare professionals, the public and other relevant groups via conference presentation and publication without any publication restrictions. TRIAL REGISTRATION NUMBER: NCT05287204.
Subject(s)
Acute Kidney Injury , Continuous Renal Replacement Therapy , Muscular Diseases , Humans , Acute Kidney Injury/etiology , Aftercare , Critical Illness/therapy , Intensive Care Units , Multicenter Studies as Topic , Observational Studies as Topic , Patient Discharge , Prospective Studies , Renal Replacement Therapy/methodsABSTRACT
We describe the development, implementation, and outcomes of an intensivist-led adult extracorporeal life support (ECLS) program using intensivists both to perform venovenous (V-V), venoarterial (V-A), and extracorporeal cardiopulmonary resuscitation (ECPR) cannulations, and to manage patients on ECLS throughout their ICU course. All adults supported with ECLS at the University of New Mexico Hospital (UNMH) from February 1, 2017 to December 31, 2021 were retrospectively analyzed. A total of 203 ECLS cannulations were performed in 198 patients, including 116 V-A cannulations (including 65 during ECPR) and 87 V-V cannulations (including 38 in patients with COVID-19). UNMH intensivists performed 195 cannulations, with 9 cannulation complications. Cardiothoracic surgeons performed 8 cannulations. Overall survival to hospital discharge or transfer was 46.5%. Survival was 32.3% in the ECPR group and 56% in the non-ECPR V-A group. In the V-V cohort, survival was 66.7% in the COVID-19-negative patients and 34.2% in the COVID-19-positive patients. This large series of intensivist-performed ECLS cannulations-including V-A, V-V, and ECPR modalities-demonstrates the successful implementation of a comprehensive intensivist-led ECLS program. With outcomes comparable to those in the literature, our program serves as a model for the initiation and development of ECLS programs in settings with limited access to local subspecialty cardiothoracic surgical services.
Subject(s)
COVID-19 , Cardiopulmonary Resuscitation , Extracorporeal Membrane Oxygenation , Adult , Humans , Retrospective Studies , CatheterizationABSTRACT
Acute kidney injury (AKI) and intensive care unit-acquired weakness (ICU-AW) are 2 frequent complications of critical illness that, until recently, have been considered unrelated processes. The adverse impact of AKI on ICU mortality is clear, but its relationship with muscle weakness-a major source of ICU morbidity-has not been fully elucidated. Furthermore, improving ICU survival rates have refocused the field of intensive care toward improving long-term functional outcomes of ICU survivors. We begin our review with the epidemiology of AKI in the ICU and of ICU-AW, highlighting emerging data suggesting that AKI and AKI treated with kidney replacement therapy (AKI-KRT) may independently contribute to the development of ICU-AW. We then delve into human and animal data exploring the pathophysiologic mechanisms linking AKI and acute KRT to muscle wasting, including altered amino acid and protein metabolism, inflammatory signaling, and deleterious removal of micronutrients by KRT. We next discuss the currently available interventions that may mitigate the risk of ICU-AW in patients with AKI and AKI-KRT. We conclude that additional studies are needed to better characterize the epidemiologic and pathophysiologic relationship between AKI, AKI-KRT, and ICU-AW and to prospectively test interventions to improve the long-term functional status and quality of life of AKI survivors.
Subject(s)
Acute Kidney Injury , Quality of Life , Humans , Intensive Care Units , Critical Care , Renal Replacement Therapy/adverse effects , Acute Kidney Injury/therapy , Critical IllnessABSTRACT
CONTEXT: During acute health decompensations for seriously ill patients, emergency clinicians often determine the intensity end-of-life care. Little is known about how emergency clinicians conduct these conversations, especially among those who have received serious illness communication training. OBJECTIVES: To determine the self-reported practice patterns of code status conversations by emergency clinicians with and without serious illness communication training. METHODS: A cross-sectional survey was conducted among emergency clinicians with and without a recent evidence-based, serious illness communication training tailored for emergency clinicians. Emergency clinicians were included from two academic medical centers. A five-point Likert scale ("very unlikely" to "very likely" to ask) was used to assess the self-reported likelihood of asking about patients' preferences for medical procedures and patients' values and goals. RESULTS: Among 161 respondents (71% response rate), 77 (48%) received the training. A total of 70% of emergency clinicians reported asking about procedure-based questions, and only 38% reported asking about patient's values regarding end-of-life care. For value-based questions, statistically significant differences were observed between emergency clinicians who underwent the training and those who did not in four of the seven questions asked (e.g., the higher odds of exploring the patient's life priorities [adjusted OR = 4.34, 95% CI = 1.95-9.65, P-value < 0.001]). No difference was observed in the self-reported rates of all procedure-based questions between the two groups. CONCLUSION: Most emergency clinicians reported asking about procedure-based questions, and some asked about patient's value-based questions. Clinicians with recent serious illness communication training may ask more about some values and priorities.
Subject(s)
Critical Illness , Terminal Care , Humans , Cross-Sectional Studies , Communication , Terminal Care/methods , Self ReportABSTRACT
BACKGROUND: The intersection of emergency medicine (EM) and palliative care (PC) has been recognized as an essential area of focus, with evidence suggesting that increased integration improves outcomes. This has resulted in increased research in EM PC. No current framework exists to help guide investigation and innovation. OBJECTIVE: The objective was to convene a working group to develop a roadmap that would help provide focus and prioritization for future research. METHODS: Participants were identified based on clinical, operation, policy, and research expertise in both EM and PC and spanned physician, nursing, social work, and patient perspectives. The research roadmap setting process consisted of three distinct phases that were time staggered over 12 months and facilitated through three live video convenings, asynchronous input via an online document, and a series of smaller video convenings of work groups focused on specific topics. RESULTS: Gaps in the literature were identified and informed the four key areas for future research. Consensus was reached on these domains and the associated research questions in each domain to help guide future study. The key domains included work focused on the value imperative for PC in the emergency setting, models of care delivery, disparities, and measurement of impact and efficacy. Additionally, the group identified key methodological considerations for doing work at the intersection of EM and PC. CONCLUSIONS: There are several key domains and associated questions that can help guide future research in ED PC. Focus on these areas, and answering these questions, offers the potential to improve the emergency care of patients with PC needs.
Subject(s)
Emergency Medicine , Physicians , Consensus , Forecasting , Humans , Palliative CareABSTRACT
Palliative care is an interdisciplinary care to optimize physical, psychosocial, and spiritual symptoms of patients and their families whose quality of life is impaired by serious, life-limiting illness. In 2021, the importance of providing palliative care in the intensive care unit (ICU) is well recognized by various studies to alleviate physical symptoms due to invasive treatments, to set patient-centered goals of care, and to provide end-of-life care. This paper summarizes the evidence known to date on primary palliative care delivered in the ICU settings. We will then discuss the potential benefits and harms of primary palliative care so that critical care clinicians are better equipped to decide what services might best improve the palliative care needs in their ICUs.
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Importance: Rural US residents disproportionately rely on emergency departments (ED), yet little is known about patient outcomes after ED visits to rural hospitals or critical access hospitals (CAHs). Objective: To compare 30-day outcomes after rural vs urban ED visits and in CAHs, a subset of rural hospitals. Design, Setting, and Participants: This propensity-matched, retrospective cohort study used a 20% sample of national Medicare fee-for-service beneficiaries from January 1, 2011, to October 31, 2015. Rural and urban ED visits were matched on demographics, patient prior use of EDs, comorbidities, and diagnoses. Thirty-day outcomes overall and stratified by 25 common ED diagnoses were evaluated, with similar analysis of CAHs vs non-CAHs. Data were analyzed from February 15, 2020, to May 17, 2021. Main Outcomes and Measures: The primary outcome was 30-day all-cause mortality. Secondary outcomes were ED revisits with and without hospitalization. Results: The matched cohort included 473â¯152 rural and urban Medicare beneficiaries with a mean (SD) age of 75.1 (7.9) years (59.1% and 59.3% women, respectively; 86.9% and 87.1% White, respectively). Medicare beneficiaries at rural vs urban EDs experienced similar all-cause 30-day mortality (3.9% vs 4.1%; effect size, 0.01), ED revisits (18.1% vs 17.8%; effect size, 0.00), and ED revisits with hospitalization (6.0% vs 8.1%; effect size, 0.00). Rural ED visits were associated with more transfer (6.2% vs 2.0%; effect size, 0.22) and fewer hospitalizations (24.7% vs 39.2; effect size, 0.31). Stratified by diagnosis, patients in rural EDs with life-threatening illnesses experienced more transfer with 30-day mortality similar to that of patients in urban EDs. In contrast, mortality differed for patients in rural EDs with symptom-based diagnoses, including chest pain (odds ratio [OR], 1.54 [95% CI, 1.25-1.89]), nausea and vomiting (OR, 1.68 [95% CI, 1.26-2.24), and abdominal pain (OR, 1.73 [95% CI, 1.42-2.10]). All findings were similar for CAHs. Conclusions and Relevance: The findings of this cohort study of rural ED care suggest that patient mortality for potentially life-threatening conditions is comparable to that in urban settings. Further research is needed to understand the sources of greater rural ED mortality for symptom-based conditions. These findings underscore the importance of ensuring access to treatment of life-threatening conditions at local EDs in rural communities, which are increasingly endangered by hospital closures.
Subject(s)
Critical Care/statistics & numerical data , Emergency Medical Services/statistics & numerical data , Emergency Service, Hospital/statistics & numerical data , Health Services Accessibility/statistics & numerical data , Hospitals, Rural/statistics & numerical data , Rural Population/statistics & numerical data , Urban Population/statistics & numerical data , Aged , Aged, 80 and over , Cohort Studies , Female , Humans , Male , Medicare/statistics & numerical data , Retrospective Studies , United StatesABSTRACT
This White Paper has been formally accepted for support by the International Federation for Emergency Medicine (IFEM) and by the World Federation of Intensive and Critical Care (WFICC), put forth by a multi-specialty group of intensivists and emergency medicine providers from low- and low-middle-income countries (LMICs) and high-income countries (HiCs) with the aim of 1) defining the current state of caring for the critically ill in low-resource settings (LRS) within LMICs and 2) highlighting policy options and recommendations for improving the system-level delivery of early critical care services in LRS. LMICs have a high burden of critical illness and worse patient outcomes than HICs, hence, the focus of this White Paper is on the care of critically ill patients in the early stages of presentation in LMIC settings. In such settings, the provision of early critical care is challenged by a fragmented health system, costs, a health care workforce with limited training, and competing healthcare priorities. Early critical care services are defined as the early interventions that support vital organ function during the initial care provided to the critically ill patient-these interventions can be performed at any point of patient contact and can be delivered across diverse settings in the healthcare system and do not necessitate specialty personnel. Currently, a single "best" care delivery model likely does not exist in LMICs given the heterogeneity in local context; therefore, objective comparisons of quality, efficiency, and cost-effectiveness between varying models are difficult to establish. While limited, there is data to suggest that caring for the critically ill may be cost effective in LMICs, contrary to a widely held belief. Drawing from locally available resources and context, strengthening early critical care services in LRS will require a multi-faceted approach, including three core pillars: education, research, and policy. Education initiatives for physicians, nurses, and allied health staff that focus on protocolized emergency response training can bridge the workforce gap in the short-term; however, each country's current human resources must be evaluated to decide on the duration of training, who should be trained, and using what curriculum. Understanding the burden of critical Illness, best practices for resuscitation, and appropriate quality metrics for different early critical care services implementation models in LMICs are reliant upon strengthening the regional research capacity, therefore, standard documentation systems should be implemented to allow for registry use and quality improvement. Policy efforts at a local, national and international level to strengthen early critical care services should focus on funding the building blocks of early critical care services systems and promoting the right to access early critical care regardless of the patient's geographic or financial barriers. Additionally, national and local policies describing ethical dilemmas involving the withdrawal of life-sustaining care should be developed with broad stakeholder representation based on local cultural beliefs as well as the optimization of limited resources.
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Critical Care , Delivery of Health Care , Critical Illness/therapy , Health Facilities , Humans , PovertyABSTRACT
BACKGROUND: Among patients with acute respiratory failure requiring prolonged mechanical ventilation, tracheostomies are typically placed after approximately 7 to 10 days. Yet half of patients admitted to the intensive care unit receiving tracheostomy will die within a year, often within three months. Existing mortality prediction models for prolonged mechanical ventilation, such as the ProVent Score, have poor sensitivity and are not applied until after 14 days of mechanical ventilation. We developed a model to predict 3-month mortality in patients requiring more than 7 days of mechanical ventilation using deep learning techniques and compared this to existing mortality models. METHODS: Retrospective cohort study. Setting: The Medical Information Mart for Intensive Care III Database. Patients: All adults requiring ≥ 7 days of mechanical ventilation. Measurements: A neural network model for 3-month mortality was created using process-of-care variables, including demographic, physiologic and clinical data. The area under the receiver operator curve (AUROC) was compared to the ProVent model at predicting 3 and 12-month mortality. Shapley values were used to identify the variables with the greatest contributions to the model. RESULTS: There were 4,334 encounters divided into a development cohort (n = 3467) and a testing cohort (n = 867). The final deep learning model included 250 variables and had an AUROC of 0.74 for predicting 3-month mortality at day 7 of mechanical ventilation versus 0.59 for the ProVent model. Older age and elevated Simplified Acute Physiology Score II (SAPS II) Score on intensive care unit admission had the largest contribution to predicting mortality. DISCUSSION: We developed a deep learning prediction model for 3-month mortality among patients requiring ≥ 7 days of mechanical ventilation using a neural network approach utilizing readily available clinical variables. The model outperforms the ProVent model for predicting mortality among patients requiring ≥ 7 days of mechanical ventilation. This model requires external validation.
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Deep Learning , Hospital Mortality , Intensive Care Units , Models, Biological , Respiration, Artificial , Aged , Female , Humans , Male , Middle Aged , Predictive Value of Tests , Time FactorsABSTRACT
Latent knowledge can be extracted from the electronic notes that are recorded during patient encounters with the health system. Using these clinical notes to decipher a patient's underlying comorbidites, symptom burdens, and treatment courses is an ongoing challenge. Latent topic model as an efficient Bayesian method can be used to model each patient's clinical notes as "documents" and the words in the notes as "tokens". However, standard latent topic models assume that all of the notes follow the same topic distribution, regardless of the type of note or the domain expertise of the author (such as doctors or nurses). We propose a novel application of latent topic modeling, using multi-note topic model (MNTM) to jointly infer distinct topic distributions of notes of different types. We applied our model to clinical notes from the MIMIC-III dataset to infer distinct topic distributions over the physician and nursing note types. Based on manual assessments made by clinicians, we observed a significant improvement in topic interpretability using MNTM modeling over the baseline single-note topic models that ignore the note types. Moreover, our MNTM model led to a significantly higher prediction accuracy for prolonged mechanical ventilation and mortality using only the first 48 hours of patient data. By correlating the patients' topic mixture with hospital mortality and prolonged mechanical ventilation, we identified several diagnostic topics that are associated with poor outcomes. Because of its elegant and intuitive formation, we envision a broad application of our approach in mining multi-modality text-based healthcare information that goes beyond clinical notes. Code available at https://github.com/li-lab-mcgill/heterogeneous_ehr.
Subject(s)
Algorithms , Bayes Theorem , Data Mining/methods , Electronic Health Records , Hospital Mortality/trends , Respiration, Artificial/statistics & numerical data , Humans , Respiration, Artificial/methodsSubject(s)
Pandemics , Rural Population , Humans , Pandemics/prevention & control , Socioeconomic FactorsABSTRACT
Background: Advance care planning (ACP) conversations are an important intervention to provide care consistent with patient goals near the end of life. The emergency department (ED) could serve as an important time and location for these conversations. Objectives: To determine the feasibility of an ED-based, brief negotiated interview (BNI) to stimulate ACP conversations among seriously ill older adults. Methods: We conducted a pre/postintervention study in the ED of an urban, tertiary care, academic medical center. From November 2017 to May 2019, we prospectively enrolled adults ≥65 years of age with serious illness. Trained clinicians conducted the intervention. We measured patients' ACP engagement at baseline and follow-up (3 ± 1 weeks) and reviewed electronic medical record documentation of ACP (e.g., medical order for life-sustaining treatment [MOLST]). Results: We enrolled 51 patients (mean age = 71; SD 12), 41% were female, and 51% of patients had metastatic cancer. Median duration of the intervention was 11.8 minutes; few (6%) of the interventions were interrupted. We completed follow-up for 61% of participants. Patients' self-reported ACP engagement increased from 3.0 to 3.7 out of 5 after the intervention (p < 0.01). Electronic documentation of health care proxy forms increased (75%-94%, n = 48) as did MOLST (0%-19%, n = 48) during the six months after the ED visit. Conclusion: A novel, ED-based, BNI intervention to stimulate ACP conversations for seriously ill older adults is feasible and may improve ACP engagement and documentation.
Subject(s)
Advance Care Planning , Crisis Intervention , Aged , Communication , Emergency Service, Hospital , Feasibility Studies , Female , Humans , MaleSubject(s)
Hospital Rapid Response Team/statistics & numerical data , Respiratory Insufficiency/mortality , Terminally Ill/statistics & numerical data , Aged , Communication , Decision Making/ethics , Emergency Service, Hospital/organization & administration , Humans , Intensive Care Units/statistics & numerical data , Intubation/methods , Physicians/psychology , Prognosis , Respiratory Insufficiency/epidemiology , Resuscitation Orders/ethics , Resuscitation Orders/psychology , Terminal Care/ethics , Terminal Care/psychologyABSTRACT
The emergency department (ED) provides immediate access to medical care for patients and families in times of need. Increasingly, older patients with serious illness seek care in the ED, hoping for relief from symptoms and suffering associated with advanced disease. Until recently, emergency medicine (EM) clinicians have been ill-equipped to meet the needs of patients with serious illness, and palliative services have been largely unavailable in the ED. However, in the past decade, there has been growing recognition from within both the EM and palliative medicine communities on the importance of palliative care provision in the ED. The past 10 years have seen a surge in EM-palliative care training and education, quality improvement projects, and research. As a result, the practice paradigm within EM for the seriously ill has begun to shift to incorporate more palliative care practices. Despite this progress, substantial work has yet to be done in terms of identifying ED patients in need of palliative care, training EM clinicians to provide high-quality primary palliative care, creating pathways for ED referral to palliative care and hospice, and researching the outcomes and impact of palliative care provision on patients with serious illness in the ED.
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Background: Older adults frequently report a preference to "trial" intubation and mechanical ventilation (MV) if faced with life-threatening respiratory failure. Understanding the anticipated outcome of unplanned MV is key to structuring a time-limited trial of treatment. Objective: To characterize the time-to-death (TTD) among adults 65 years of age and older, who undergo emergency intubation and MV. Design: Retrospective cohort study. Setting/Subjects: All patients 65 years of age and older, who underwent emergency department (ED) intubation from 2008 to 2015, from 417 hospitals were included. Measurements: The primary outcome was TTD after emergency intubation. Results: We identified 41,463 ED encounters. The median TTD was three days (interquartile range, IQR, 1-8). There was a statistically significant change in the median TTD by age decile, with the shortest TTD, two days, in the oldest age group (p < 0.001). TTD was shortest among those with myocardial infarction (one day, IQR 4) and sepsis (two days, IQR 5). Bivariate analysis comparing TTD by Charleston Comorbidity Index (CCI) revealed a trend of increasing TTD with increasing CCI score among decedents. Patients with a CCI of 0 had a median TTD of one day (IQR 4), whereas the median TTD among those with a CCI >4 was four days (IQR 9). Conclusions: In a large, nationally representative cohort of older adults undergoing ED intubation, the median time from intubation to death was short; however, the length of time between intubation and death varied considerably by principal diagnosis. This information will help guide providers' prognostication after emergency intubation and enhance serious illness conversations by informing expectations. Tweet: Thirty-five percent of older adults die after ED intubation-most only survive two or three days after intubation.
Subject(s)
Emergency Service, Hospital , Respiratory Insufficiency , Aged , Humans , Intubation, Intratracheal , Respiration, Artificial , Retrospective StudiesABSTRACT
BACKGROUND: The Good Outcome Following Attempted Resuscitation (GO-FAR) Score uses pre-arrest factors to predict survival after In-Hospital Cardiac Arrest (IHCA) with minimal neurological dysfunction, (cerebral performance category (CPC) ≤1). Moderate neurological dysfunction (CPC ≤2) may be a more acceptable outcome. OBJECTIVE: To predict survival after IHCA with mild or moderate neurological dysfunction based on pre-arrest factors. METHODS: 52,468 patients with IHCA from 2012-2017. Data was divided into training (44%), testing (22%), and validation (34%) sets. Univariate analysis was used to identify variables with >3% difference in survival with CPC ≤2. These variables carried forward to the multivariate logistic regression model. The most parsimonious model that best classified patients as having a very poor (≤5%), below average (≤10%), average (11%-30%), or above average (>30%) likelihood of survival with CPC ≤2 was chosen. RESULTS: Age >85, admission CPC <2, and non-surgical admission were strongly association with poor survival (-12.1%, -14.4%, and -18%, respectively). Nine variables were included in the logistic regression analysis. The final updated model, GO FAR 2, categorized 6.2% of patients with a very poor predicted survival, 24.8% of patients with a below average predicted survival, and 11.3% with above average predicted survival. The observed survival among those with very poor predicted survival was 4.5%. CONCLUSION: The GO FAR 2 score provides clinicians with a prognostic estimate of the likelihood of a good outcome after IHCA based on pre-arrest patient factors. Future research is required to validate the GO-FAR 2 score.